Alternative Dispute Resolution

All Ohio workers' compensation managed care organizations (MCOs) are required to have an Alternative Dispute Resolution (ADR) process. ADR is intended to handle medical disputes regarding quality assurance, utilization review, medical necessity and other treatment and provider issues. In the state's Health Partnership Program (HPP), for the first time, providers are able to initiate a medical dispute involving a workers' compensation claim. Any party initiating a medical dispute should contact the MCO directly. Medical disputes may arise involving:

Employer
Injured worker
Provider
Ohio Bureau of Workers' Compensation (BWC)
MCO

The goals of ADR include:

Facilitate resolution of disputes through negotiation by introduction of an objective third party at the MCO and BWC level.
Support and complement medical case management continuum.
Ensure fairness and due process to parties.
Avoid litigation.
Preserve relationships of parties.
Strive for satisfaction of parties.
Improve communications.
Promote durable outcomes.
Maintain flexibility, make adaptations.
Support spirit and intent of HPP.

ADR Requirements

Injured workers, employers and their representatives, or providers may initiate ADR for MCO-managed claims by contacting the employer's MCO in writing, detailing the specific appeal of an MCO decision. This must occur within 14 calendar days of receipt of written notice of an initial MCO treatment reimbursement determination.

The MCO must process any appeal it receives and does not have the jurisdiction to state that it has not received an appealable issue. However, the MCO may respond that the time frame for the dispute has expired as long as it specifies the unmet time frames and references its denial notifying parties of the time frames. The MCO shall respond to the appeal regardless of whether or not medical documentation was received with the appeal. An ADR appeal letter does not have to contain the word "appeal" for the MCO to accept the appeal letter.

The MCOs must have a medical dispute resolution process with only one level of review for medical disputes filed on or after January 1, 1999. The independent level of review shall consist of a peer review conducted by an individual or individuals licensed pursuant to the same section of the Revised Code as the health care provider requesting the disputed issue. The peer review opinion must be legibly documented (typed is preferred) and signed. The name must be printed under the physician signature.

Treatment reimbursement decisions shall be communicated in writing (no verbals), with an appropriate explanation, within three business days from the MCO's treatment reimbursement request receipt date.

Per Rule 4123-6-16, the MCO has 21 days to complete its review of the appeal and notify in writing the parties to the dispute and their representatives of its decision. The MCO will maintain the dispute information for 10 days following its final decision to provide time for appeal to BWC.

Treatment reimbursement approvals shall be provided to employers and their authorized representatives. Treatment reimbursement denials shall be provided to injured workers and their authorized representatives. The MCO shall inform BWC and providers of all treatment reimbursement decisions.

All written decisions from the MCO must contain language for appeal, including the time frame and the appeal process for the parties to the dispute. This affords due process as mandated in Rule 4123-6-16(C). The time frame for response to appeal the initial MCO decision is 14 days from receipt of the initial MCO decision and seven days from receipt of the MCO decision to the BWC level.

Contact Information

Appeals involving University Hospitals CompCare should be submitted to: